Strategy To See

Encouraging Efficient Use of Vision in Students with CVI

Created By Diane Sheline, CTVI, CLVT

www.StrategyToSee.com

diane@strategytosee.com

The following are suggestions to use with infants, young children, and students who have Cortical Visual Impairment (CVI) or who are suspected to have a brain damage related vision loss.  These suggestions are intended to encourage students with CVI to use their vision more efficiently.  These suggestions correlate loosely with functioning levels/Phases described in Dr. Christine Roman’s book, Cortical Visual Impairment – An Approach to Assessment and Intervention. The reader is encouraged to read through all suggestions, as some students functioning in Phase III might still benefit from suggestions in Phase II or even Phase I, students in Phase II might also benefit from suggestions in Phase I and Phase III, etc.  Use the suggestions, especially in Phase I, in conjunction with regularly occurring activities in daily life such as feeding, toileting, grooming and amusement activities.  These are general guidelines; no individual student with CVI will ever fit into any one category.

Students Functioning in Phase I

Students in Phase I are generally functioning at a level where they are just beginning to alert to light and objects with movement. The focus in this phase is the building of visual behaviors.  Environmental complexity and distractions need to be strictly controlled.  Sound can sometimes be used to initiate visual attention, but should be discontinued as soon as the child visually locates the target.  Often, the auditory learning channel is the strongest and if a sound source continues longer than necessary, the child may look away to attend to the sound.  When the child looks away, he/she discontinues learning through the visual channel and discontinues building the neurological pathway that helps the child make sense of what he/she sees.  The same applies to tactual input.  The child at this stage may notice visual targets up to about an arm’s length away (24” to 36”).  Some suggestions offered in Phase II and Phase III may also be applicable to a child functioning in Phase I.

Considerations

• Interview parent or caretaker; learn about most frequently viewed targets and situations when student most frequently uses his/her vision; knowledge of what the student likes/dislikes should be built into his/her learning activities
• If visual learning occurs away from home, use familiar toys or visual targets from home
• Be aware of prescription medications the student takes; some may cause student to be drowsy or have visual side effects
• Watch for signs of visual fatigue, overstimulation, and/or stress.  Signs include vocalization, eyes closed or sleeping frequently, hand or leg muscle tension/twitching, yawning, and “fading” behavior such as light gazing.
• Allow for intermittent break times
• Plan activities during the time of day when student is alert, ready to learn
• Proper positioning will be crucial.  If the child is not in an aligned or supported body posture, he/she will have difficulty attending to the visual target, focusing, and using efficient vision in general.

Environment

• Reduce auditory distractions when visual learning is taking place – turn off the TV, turn off the radio, move away from neighboring students who are very vocal/loud, turn off cell phones, encourage quiet from other adults/caretakers in the room
• Reduce tactual distractions when visual learning is taking place – resist the temptation to give a rub on the back or a pat on the arm as a “good work” gesture; Care should be taken not to bump into a wheelchair or bed. When there is a need to encourage the student to touch something, use hand-under-hand technique – more information at: “The Language of the Hands:  Hand-Under-Hand Technique” http://nationaldb.org/NCDBProducts.php?prodID=47
• Reduce or eliminate visual distractions that may interfere with visual attending behavior (i.e. sudden movement off to the side) – Use a 3 panel curtain or block from distractions by use of positioning
• Work surface should be free of visual clutter
• Use a white or black cloth to cover distracting background items
• Walls and bulletin boards should be simple and free from clutter
• Carpets should be plain, no pattern
• Turn student away from sunlight streaming through windows or blinds
• Care should be taken that no sparkling jewelry is worn, distracting the student from the visual target
• Reduce or eliminate use of perfume, cologne, or other strong odors/scents
• Maintain a comfortable room temperature

Near Visual Field

• Present visual targets in preferred visual field (usually left field or right field, generally not central and rarely lower)
• Often, students have difficulty detecting targets in lower visual field – raise targets up
• Use of a custom made slant board, reading stand, felt covered tri-fold board or angled dry erase board are helpful in creating contrast in near visual field
• Teacher or caretaker should wear plain colored clothing that creates contrast behind the target being presented; black smock or apron works well
• Use of a black cloth or white cloth also helps to create contrast
• Use a “CVI Den” to help with contrast and to reduce visual distractions

Visual Target

• Use of objects with a single color, especially red or yellow, but sometimes other bright primary colors including orange and purple
• Present visual targets against plain, visually quiet backgrounds (black felt board, white cloth, black cloth) again, attention to contrast will be important
• Place targets no further than an arm’s length away (about 24” to 36”)
• Pair visual target with movement (slinky), especially in the peripheral fields; sometimes moving the object helps the child to see it better
• Use visual targets with light qualities (colorful light or blinking light)
• Use visual targets with reflective qualities (mylar)
• In some cases, pairing visual targets with sound will initiate looking behavior
• In some cases, pairing visual targets with a touch cue will initiate looking behavior
• May turn head to one side or the other when reaching for object; appears as if they are looking away from the visual target, but may be using their peripheral vision
• Use real objects whenever possible.  When using an Anticipation Calendar, use real objects that the child has had a meaningful experience with (see http;//www.tsbvi.edu/Outreach/seehear/archive/Let Me Check My Calendar.htm) For example, use a real cup rather than a picture of a cup.  Relate what is being seen to function, whenever possible
• Present real objects against high color contrast (light colored foods against dark plates with a contrasting background color)
• Watch for subtle response cues to visual targets including; shifts of gaze or body positions, changes in breathing patterns
• Use color
  • Keep color of common objects consistent until association is established (if student is attracted to red, use a red cup during meals; at school and at home)
  • Encourage looking at mom by use of bright colored lipstick
  • A bright yellow colored pom pom might encourage reaching behavior
  • Bright, primary colors are best; red, yellow, purple, and orange work well

Lighting

• Provide additional, supplementary light shining on target of interest; 100 LED bright flashlights work well
• Shine light on target of interest without attracting student’s attention to the light source
• Care should be taken to avoid glare
• Do not shine a bright light into the eyes of the student
• Use of plug-in, natural desk lights work well to shine on targets and workspace (but you are restricted to the length of the power cord)
• Use of Light Box (with a Swirly Mat) and other lighted toys/targets are beneficial
• Care should be taken when using blinking or flashing lights (this sometimes sets off a seizure)
• When using a supplementary light shining on a target to encourage visual attending behavior, dim the overhead lights and reduce natural light coming through windows
• A small number of children with CVI experience photophobia (light sensitivity)

Positioning

• Ensure that the student is in a comfortable, secure position when use of vision is the goal
• Do not try a new stander or chair (or other new position) when working on use of vision
• Work closely with the PT or therapist to determine the best position to help student feel secure and comfortable
• When a child’s head rolls to one side, the visual field involuntarily shifts; provide appropriate head support
• Try a variety of positions to determine which one supports visual attending behaviors

Routine

• Repetition, repetition, repetition: use the same objects and the same process each time to provide familiarity, reduce latency period, and shorten “warm up” time
• Same individual working with the child in the same way, again and again
• See, “Steps for Incorporating Activity Routines into Your Practice at:

http://www.tsbvi.edu/Outreach/seehear/fall02/activity-routines.htm

• Repetition and practice is how a child with CVI learns to integrate new knowledge, remember it for a future session, and put it to use

Familiarity

• Use objects that the student is familiar with and uses on a daily basis; use of objects that are familiar often result in increased visual attention
• Objects used in the classroom setting should also be used at home (and vice versa)
• Familiar objects often include bottle, cup, spoon bowl, plate, comb, washcloth, noisy or musical toy, and diaper
• Work with the student in a familiar environment, when possible (this includes when you meet a new student for evaluation; try not to take them to an unfamiliar testing room)

Pacing

• Slow down presentation of visual objects and targets
• Allow student time to process what is being seen and respond to what is being presented

Mobility

• Use lights to encourage reaching behavior/movement
• Use mylar pom poms and other reflective toys with light shining on them to encourage reaching behavior/movement
• Present targets against a contrasting color

Students Functioning in Phase II

A student functioning in Phase II is using his/her vision more consistently, but often not efficiently.  The teacher and caretaker will want to work towards encouraging the child to use their vision during daily routines and activities. Generally, students at this stage are able to visually attend to targets up to about 4 or 5 feet away.   Many of the above considerations may still apply and some suggestions in Phase III may also apply.

Considerations

• Interview parent or caretaker; always the best source of information
• Be aware of the prescription medications the student takes; some may cause student to be drowsy or have visual side effects
• Providing a routine and structure/sameness continues to be important
• Use of cues, signals and symbols might be considered at this stage (see “Non-Verbal Communication: Cues, Signals and Symbols” at; http://www.tsbvi.edu/Education/vmi/nonverbal.htm
• Encourage students to learn by being active (see “An Introduction to Dr. Lilli Nielsen’s Active Learning” at

http://www.tsbvi.edu/Outreach/seehear/summer99/nielsonintro.htm

Environment

• Reduce auditory distractions – turn off the TV, turn off the radio, move away from neighboring students who are vocal/loud, turn off cell phones, encourage quiet from other adults/caretakers in the room
• When an auditory cue is used/needed to encourage looking behavior (and develop language), use the following suggestions
  • Explaining what to look for and where to look often helps a child with CVI see better
  • Use descriptive words about the object or visual situation
  • Use voice intonation that matches the word used
  • Use “Verbal Cuing” (the ball is by the light)
  • Use an interesting noise or a few words of praise, along with a visual target, to increase looking behavior (crunchy/scratchy noise when you shake a mylar pom pom)
  • If possible, try to establish looking behavior first, then give verbal praise or description; make sound a “reward” for looking behavior
  • Reduce tactual distractions when visual learning is taking place
    • Resist the temptation to give a rub on the back or a pat on the arm as a “good work” gesture
    • Avoid grabbing a hand to help student touch something
    • When a tactual cue is needed to encourage looking behavior, use the following suggestions
      • Touch the object of interest to the child’s hand to direct visual attention
      • Run the object of interest down the side of the child’s arm to his/her hand, to direct visual attention
      • Reduce visual distractions when visual learning is taking place
        • Sunlight through the window or light from a lamp may be a distracter
        • A moving ceiling fan may be a distracter
        • Sudden movements in the peripheral field should be restricted
        • Work surface should be free of visual clutter

Near Visual Field

• Allow student to get as close to target as needed; this reduces visual complexity
• Present visual targets in student’s preferred visual field
• Use of a slant board, reading stand, tri-fold black felt covered board, or All-In-One Board is helpful in bringing target into visual field (black painted clothes pins with Velcro work well on felt covered slant boards, to hold visual targets in place)
• Allow child to avoid visual gaze, if necessary: may turn head away from target when reaching for it
• Work surface should be free of visual clutter (no stick on alphabet strips, name stickers, notebooks, pens, cell phones, etc.)

Visual Target

• Use common objects in a bright, preferred color (or possibly 2 or 3 colors)
• Use visual targets that have movement
• Present one visual target at a time
• Use reflective/shiny material applied to common objects used daily, to help direct visual attention (red, reflective Contac paper, reflective red wide ribbon, etc.)
• Use lighted targets or blinking lights
• Use of Anticipation Calendar with familiar objects (see: http://www.tsbvi.edu/Outreach/seehear/archive/Let%20Me%20Check%20My%20Calendar.htm
• Spacing of visual targets will be important, when more than one target is used
• Limit number of targets presented (one or two at a time is best)
• Use of Routines and keeping information simple, constant and predictable will continue to be important
• Use colored or lighted materials for daily living skills (e.g. a red, blinking light drinking cup)
• Providing good color contrast will continue to be important
• Pictures should be simple, one to a page when using books
  • Primary books that have reflective qualities are great for this stage
  • Eliminate details that are not important to the page (white out page number, white out all but outer black outline of picture, etc.)
  • Use color
    • Use color to highlight aspects of objects, shapes, and print

Lighting

• Lighting continues to be an important factor to initiate looking behavior and to focus attention on the target of interest
• Present visual targets on a Light Box (some Light Boxes can be slanted to bring targets into visual field)
• Use of a 100 LED flashlight or supplementary desk light shining on visual targets will be important
• Eliminate glare on all surfaces (do not laminate high use targets)
• Dim overhead lights to emphasize lighted visual target; this also reduces environmental clutter and complexity

Positioning

• Continue to work with PT to determine best position for students with Cerebral Palsy or students in wheel chairs
• If student is on their side on a bed, use of a modified CVI Den helps to eliminate visual clutter and focus attention
• Use head supports, tumbleforms, and angle wheelchair into positions so student can access best field of view
• Remember that the goal is to use vision; if the student is continually working on holding up their body so they won’t tip over, they cannot be using their visual channel for learning

Familiarity

• Use familiar real objects (cup, bowl, plate, spoon, toy, etc) one or two at a time, well spaced
• Use objects and toys in child’s preferred color

Pacing

• Slow down presentation of visual objects and targets
• Allow student time to process what is being seen and respond to what is being presented

Mobility

• Use lights by themselves or shining on targets to encourage reaching behavior and movement
• Use single colored objects/mylar objects presented against solid colors to encourage reaching behavior and movement
• Use objects that are familiar
• Present targets against good color contrast

Students Functioning in Phase III

A student in Phase III is developing more typical visual behavior but may continue to have difficulty in a complex environment, when required to use distant viewing and/or with their visual field (especially lower).   The “crowding phenomenon” or complexity often continues to be a problem causing difficulty for the student differentiating between background and foreground visual information.  Lighting will continue to be important, especially for mobility purposes.  Many of the above considerations may still apply.

Considerations

• Students functioning in Phase III may still need additional response time, particularly if the child is tired, stressed, ill, or has just had a seizure
• Interview parent or caretaker
• Be aware of the prescription medications the student takes; some may cause student to be drowsy or have visual side effects
• Be specific about what you want the student to look at or do

Environment

• Complexity and crowding are still a concern in some areas
  • Books, worksheets, and other two dimensional materials may still need to be modified
  • Distant targets (10-15 feet) will need to stand out in some way or complexity will need to be reduced
  • Student continues to benefit from increased lighting on both near materials and in the general environment (hallways and stairwells)

Near Visual Field

• Bright colors will still draw student’s attention
• Work surface should be free of visual clutter (no stick on alphabet strips, name stickers, notebooks, pens, cell phones, etc.)
• Present targets in student’s best visual field
  • Allow student to move materials where they can see them most efficiently
  • Determine if student views materials more efficiently in horizontal plane or vertical plane
  • Use a slant board or reading stand
  • Allow student to tilt or turn his/her head to the best angle for viewing

Visual Targets

• Spacing of visual targets may continue to be important; reduce crowding/complexity
  • If student is starting to read, use of a program with good spacing (words and pictures) will be important; The Edmark Program or the “Mac and Tab” Primary Phonics (K-2) series are examples
  • Use books with one clear, simple picture on a contrasting simple background
  • Develop custom worksheets and provide good spacing between words and between sentences (easy to do on the computer)
  • Limit the number of words/sentences on a sheet (more white space)
  • Use color
    • Outline letters or numbers with a red Sharpie
    • Highlight aspects of shapes, objects, and print with a colorful highlighter
    • Highlight the answer line on worksheets (be consistent in the use of one color on all answer lines/worksheets)
    • Highlight target or word with a yellow overlay or yellow transparency
    • Pastel colored pictures should be re-colored with bright primary colors
    • Brightly colored shoe laces; one color for the left shoe and one color for the right shoe
    • Specific colored tote boxes for specific items; blank paper in one colored tote and completed assignments in another colored tote
    • Clearly mark the beginning and end of a line of print with marker or highlighter (use green marker outlining first letter in line – red marker outlining last letter in line; use highlighter reusable tape; use colored stick-on dots by Dennison, etc.)
    • Use colorful/reflective Contac Paper to stick on and outline targets of interest
    • Black lined, well spaced, simple pictures (no inner details) seem to work best (avoid photographs until student is functioning at a high Phase III level)
    • Student may move closer to materials to reduce crowding and other visual distracters
    • Student may turn his/her head when reading
    • Providing good color contrast will continue to be a key factor
    • When looking at multiple shapes, numbers or letters, encourage the student to track with finger; point to each symbol and slide their finger from target to target
    • Keep items on desk to a minimum; emphasize organization
    • Simplify visual targets/reduce the “crowding phenomenon”
      • Use window markers to emphasize visual target of interest (cut a “window” in black construction paper to outline target of interest)
      • Use Bright Line Markers and/or black paper markers
      • Use correctional fluid to white out any details that are distracting and unnecessary
      • Cut or fold worksheets/papers to allow only small parts to show at a time – reduce the amount of information presented

Distant Visual Field

• Use color to draw attention to landmarks (outline a water fountain with red mylar wrapping paper to signal where to turn in a hallway or outline the classroom door in red duct tape to indicate the correct location)
• When student is trying to locate a person at distance, use of bright colored clothing is helpful (brightly colored hat)
• Use black “frames” to attract attention to distance targets (use precut, black mat board frames from craft store; they come in various sizes)
• When encouraging student to see a target in the distance, use a verbal prompt and a large visual target to “cue” the student to the chosen target (“Look at the big green tree then the brown building)

Lighting

• Working in a well lit environment will continue to be beneficial
• Watch for shadows as student bends over work
• Use of a battery powered light is helpful for students moving from class to class
• Use a PowerPoint Presentation to teach concepts; dim overhead lights, use programs that have movement, use a cursor that provides movement qualities
• Eliminate glare on computer monitors and workspace

Routines

• All teachers, paraprofessionals, caretakers should follow the same teaching procedures both at school and at home (e.g. yellow highlighter on answer line)
• Use of the same materials at school and at home will be important (e.g. same color highlighter)
• Good communication between school and home will be essential

Positioning

• Position student so he/she is better able to use preferred visual field (if they are better able to use their far right visual field, they should be sitting towards the left side of the classroom)
• Allow student to tilt/turn head to the best viewing position
• Seat student under overhead lighting so that shadows are not cast on their near work
• Seat students who benefit from increased illumination near a wall outlet (to plug in a desk light), when possible

Mobility

• Watch for difficulties with lower visual field and mobility (descending stairs)
• Use brightly colored reflective tape to mark stairs and locations of interest
• When mobile, travel in brightly lit hallways and stairwells
• Use a brightly colored rug or other symbol to highlight a landmark, then gradually withdraw the symbol and just use the landmark
• Student’s table/desk will stand out by creating a yellow “ink blotter” on the workspace; keep in place with clear Contact Paper
• Student’s chair will stand out by using a different color from the others
• Encourage policy of “slow, look, check, go” using verbal prompts, or a tap on the shoulder when there is uneven ground

PE Considerations

• Teammate may need to verbalize where the ball is
• Distant PE equipment that is brightly colored and has movement qualities will be easier to locate and see (i.e. swinging bright blue swing)
• Use of yellow or amber/orange tinted sunglasses help to make outdoor objects stand out
• Student may benefit from modifications in PE equipment
  • Brightly colored balls, beanbags, and birdies
  • Brightly colored bases for baseball
  • Teammates all wearing the same bright colored tee shirt will be easier to locate on a field